Director of Payer Contracting & Strategy
carepoint pharmacySchaumburg, IL
Director of Payer Contracting & Strategy
carepoint pharmacySchaumburg, ILManager L7
Direct Health and Medical Insurance CarriersPharmacy Benefit Management and Other Third Party Administration of Insurance and Pension FundsPharmacies and Drug Retailers
APPLY NOWDirector, Payer Contracting and Strategy
Location: Schaumburg, IL (hybrid) or remote, with travel as required
Company: Carepoint Pharmacy
About Carepoint Pharmacy:
Carepoint Pharmacy is a private equity-backed, digital-first specialty pharmacy headquartered in Schaumburg, Illinois. We specialize in dermatology, women’s health, allergy and immunology, and eye care, providing home delivery to patients across all 50 states through our national digital pharmacy model.
Position Summary:
- Owns Carepoint Pharmacy's relationships with pharmacy benefit managers, health plans, Medicaid fee-for-service and managed care programs, Medicare Part D sponsors, and third-party network administrators.· Accountable for network access, credentialing and recredentialing, reimbursement terms, contract performance, and the payer-facing components of audit defense and dispute resolution.· A build role establishes the payer function, sets its strategy, and executes it personally before hiring against it, building the payer contracting team as volume warrants.· Leads negotiation of participation agreements, amendments, rate schedules, reimbursement methodology, and performance terms with PBMs, plans, and network administrators, modeling contract economics with finance before execution.· Owns payer credentialing and network applications across commercial, mail-order, specialty, Medicaid, and Medicare Part D networks, and secures limited-distribution and preferred-network designations for manufacturer products.· Monitors contract compliance and reimbursement accuracy, pursues recovery of underpayments and misapplied rates, and leads the payer-facing side of desk and on-site audits.· Works directly with the COO and partners cross-functionally with pharmacy operations, finance, compliance, and business development.
Position Requirements:
- 8+ years in pharmacy or healthcare payer contracting, managed care, or network management, with direct responsibility for negotiating PBM or health plan agreements.· Demonstrated experience credentialing a pharmacy into commercial, Medicaid, and Medicare Part D networks, including mail-order and specialty designations.· Working knowledge of pharmacy reimbursement mechanics: AWP/WAC/NADAC-based pricing, effective rate guarantees, DIR and performance-based fees, MAC lists, and specialty carve-outs.· Experience responding to payer and PBM audits and negotiating audit findings.· Strong contract drafting and redline skills; comfortable working directly with legal counsel.· Financial modeling sufficient to evaluate contract economics independently.· Established relationships within PBM, health plan, or Medicaid managed care network teams.· Bachelor's degree in business, healthcare administration, finance, or related field, or equivalent experience.· Ability to travel up to 25%, including to industry conferences with payer presence (e.g., Asembia, PCMA).
Preferred:
Experience at a specialty, mail-order, or digital pharmacy, or at a PBM or plan on the network side; experience securing limited-distribution or preferred-network status; familiarity with dermatology, women's health, allergy and immunology, or ophthalmic product markets; PharmD, JD, MBA, or MHA; experience building a function in a founder-led or high-growth
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Level
Manager L7
Location
Schaumburg, IL
Occupation
Pharmacists
Industry
Direct Health and Medical Insurance Carriers
Posted
today